“I DON’T WANT ALL MY BABIES TO GO TO THE GRAVE ...



“I DON’T WANT ALL MY BABIES TO GO TO THE GRAVE”: PERCEPTIONS OF PRE-TERM BIRTH IN SOUTHERN MALAWI.

Rachel Tolhurst (BA, MA, PhD) 1, Sally Theobald (BA, MA, PhD, corresponding author) 1,2, Edith Kayira 3, Chikondi Ntonya 3, George Kafulafula (BSc,SASOG)4, Jim Nielson (MD, FRCOG)3,5, and Nynke van den Broek (BSc, MRCOG, PhD)1,3

1. Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Tel: +44 (0)151 705 3251, fax: +44(0)151-705-3364

2. Research for Equity and Community Health (REACH) Trust, P.O. Box 1597, Lilongwe, Malawi.

3. Malawi-Liverpool Wellcome Program

4. Department of Obstetrics and Gynaecology, College of Medicine , Malawi

5. School of Reproductive and Developmental Medicine, University of Liverpool, UK

“I don’t want all my babies to go to the grave”: perceptions of pre-term birth in Southern Malawi.

Structured Abstract

Objective: To investigate women’s, men’s and health care providers’ perceptions of pre-term birth , infections in pregnancy, and perinatal mortality in Namitambo, Southern Malawi

Design: A Qualitative study using Focus Group Discussions, critical incidence narrative and key informant interviews. The framework approach to qualitative analysis was deployed.

Setting: Namitambo, a rural area in southern Malawi

Participants: Women who have experienced pre-term delivery, groups of mothers, fathers and grandmothers, health care providers, traditional birth attendants and healers.

Findings: Four key inter-related themes grounded in community interpretative frameworks emerged: (1) community conceptualisations of pre-term birth (the different terminologies used); (2) perceived causes of pre-term birth (namely, illnesses – both ‘modern’ and traditional, violence, witchcraft, ideas relating to impurity, heavy work, inadequate food and inappropriate use of medicine); (3) perceived strategies to prevent pre-term birth (namely, using formal health services, treatment for sexually transmitted infections, using condoms and stopping violence) and (4) barriers to realising these strategies, such as lack of food, money and women’s autonomy in health seeking.

Key conclusions: There are both differences and commonality in health care providers’ and communities’ understandings. Additional dialogue and action is needed within the health sector and community to address the problem of pre-term births. This includes strategies to enable both health care providers and community members to reflect on their perceptions and practices (eg via action research and interactive drama); identy and build on areas of common concern (such as poor pregnancy outcome) and enter into partnerships with non-formal providers. Action is also needed beyond the health sector, for example in campaigns to reduce gender based violence.

Key words: pregnancy outcome, premature birth, Malawi, sub-Saharan Africa, qualitative research

“I don’t want all my babies to go to the grave”: perceptions of pre-term birth in Southern Malawi.

Introduction

In this paper we present qualitative data on community perceptions of pre-term birth in the Namitambo District of Southern Malawi, and discuss implications for policy and practice in the health sector and beyond.

An estimated 4 million neonatal deaths occur each year accounting for almost 40% of deaths in children under 5 years (Lawn et al 2004). Approximately 99% of newborn deaths take place in developing countries, mostly in homes and communities. (Bhutta et al 2005) The contribution of preterm birth is very significant. We have recently reported the incidence of preterm birth (birth before 37 completed weeks gestation) to be unexpectedly high with figures (using ultrasound scan dating of pregnancy) of between 25-30% in an anaemic population (van den Broek et al –in press) and 20% in a population of unselected rural women in Namitambo (van den Broek et al 2005). Another study in Malawi similarly reported an incidence of 22% (Kulmala et al 2000). There are compelling data to link infection, and especially lower genital tract infection with preterm labour and delivery (Lamont & Fisk 1993; Sebire 2001; Steer 2005). The populations studied in Malawi are representative of others in sub-Saharan Africa and although there is a paucity of data at present, the high burden of maternal infection coupled with high perinatal mortality rates in many countries suggests preterm birth is a key contributing factor to poor pregnancy outcome. (Steer 2005).

Babies born preterm are more likely to die than babies born at term (van den Broek et al 2005) and preterm birth contributed to over 50% of all neonatal mortality in the study by Kulmala et al (2002). For surviving babies, prematurity confers an increased chance of long term neuro-developmental difficulties that include, at one end of the spectrum, cerebral palsy, and at the other, more subtle educational and social difficulties. There is an additional dimension to the problem that has not to our knowledge been highlighted before; the dangers of increased maternal mortality and morbidity associated with high parity are probably in part explained by the repeated efforts of women with poor pregnancy outcome to achieve their desired family size.

A clinical trial is underway in southern Malawi (including Namitambo), which addresses the effectiveness of antibiotic prophylaxis to prevent pre-term delivery. However, bio-medical knowledge is only one starting point for intervening to improve rates of pre-term delivery. It is important to understand the perceptions of the problem in order to develop effective prevention approaches. We were unable to find any studies in the international literature that focused on lay perceptions of pre-term birth in the developing country setting. In response to this gap we conducted a qualitative research project to explore community understandings of pre-term birth in Southern Malawi.

Methods

The aim of the study was to investigate women, men and health workers’(formal and non-formal) perceptions of pre-term birth, infections in pregnancy, and perinatal mortality in Namitambo, Southern Malawi.

Recruitment and data collection

Qualitative methods offer most potential for understanding the concepts and perspectives of different groups in the community, including the poor and disadvantaged, by enabling them to express their lived realities (Aubel et al 1991; Eng et al 1990; Pope and Mays 1995). The main methods used were Focus Group Discussions (FGDs), Critical Incidence Interviews (Barnett & Abbatt 1990) and in-depth interviews with key informants, all of which were conducted by female research nurse-midwives, led by the third and fourth authors. Table 1 shows the respondents for each method.

INSERT TABLE 1

All findings are referred to as FGD with mothers, fathers or grandmothers # 1- 7, CI Incidence Interviewee # 1-11, etc.

Women for Critical Incidence (CI) interviews were recruited at Namitambo health centre, from family planning and ante-natal clinics, and interviews were carried at the health centre. Participants from 15 FGDs were recruited in 6 villages in Namitambo district; two were recruited at Namitambo health centre. There were relatively large numbers of people participating in the FGDs recruited in the village setting (between 6 and 14 people in a group as compared to the norm of 8-12). A large number of people in each community showed an interest in joining the groups and the team felt it would be counterproductive to refuse them the opportunity to participate. The first two FGDs were held in Namitambo health centre. During reflection on the process and outcomes of these discussions the team felt that the participants had been relatively subdued and constrained, which might have been due to the clinic setting. We therefore decided to hold the remaining FGDs in communities, where discussions were much livelier and appeared more frank. The slight limitation of the larger group size was considered less important than ensuring the ‘credibility’ of the data. (Pretty 1993) All interviews and discussions were held in Chichewa, the local language. The possibility of recruiting male researchers to conduct the FGDs with fathers and male key informants was discussed amongst the research team, who concluded that female facilitators would be acceptable to male participants. Male participants appeared comfortable during the discussions and interviews.

Ethical considerations, data management and analysis

Ethical approval was obtained from the College of Medicine Research Committee, Malawi and permission to work at Health Centres and Hospitals in the region from the Ministry of Health. Informed consent was sought from all individuals participating in interviews and group discussions after the purpose of the research and specific activity for which participation was being solicited was explained. The names of participants in both individual interviews and focus group discussions were not recorded to further protect privacy and confidentiality. Interviews and discussions were taped, transcribed and translated into English by the research nurse-midwives. Data analysis was carried out in an iterative way throughout data collection, using the framework analysis approach (Ritchie et al 2003). A framework for data analysis was developed, using the research questions and new issues arising. This was then used systematically to identify major and minor themes and interrelationships. To improve trustworthiness, data from different sources, such as individual interviews and focus group discussions, was compared to triangulate findings (Patton 1990). All members of the research team were involved in the analysis to enhance the ‘confirmability’ of the findings through bringing a range of perspectives and positionalities to bear on the data (Pretty 1993). Dissemination workshops were held with the community and health care providers and findings were also shared through speeches, drama and songs.

Characteristics of the participants

Table 2 summarises the key characteristics of participants recruited.

INSERT TABLE 2

CI interviewees had experienced between three and eight pregnancies each. Over half (seven) of them had experienced one premature birth, three had experienced two, and one had experienced six. All had at least one live child, but all had experienced the death of at least one child.

Findings

In this paper we focus on presenting the perceptions of mothers, fathers and grandmothers and women who had experienced pre-term delivery including views of health workers, TBAs and traditional healers where they are relevant to issues raised by community members. We will concentrate on the four major themes emerging from our data: first, the community conceptualisations of various birth outcomes; second, the perceived common causes of these outcomes; third, the potential and commonly used strategies to prevent these outcomes; and fourth, the perceived barriers to successfully following these strategies.

Figure 1 summarises these themes which are subsequently explored in more depth.

INSERT FIGURE 1.

Community conceptualisations of pre-term birth and pregnancy loss (Area 1, Figure 1)

The majority of mothers and grandmothers, and some of the men felt that in a normal pregnancy, delivery occurs after nine months. This was said to be due to “the way the world is” or “God’s plan” and some observed that by this time the baby is strong and well formed. However, some felt that it was also normal to deliver at eight or eight and a half months, “if God made them like that”. A minority of mothers and grandmothers said that delivery can take place after ten months, with some mothers saying that they had delivered at ten, twelve, thirteen or fourteen months, and gave birth to a big and mature baby. However others said that it is not normal for a pregnancy to last ten months or more and this may be a sign of witchcraft. Many respondents said that their knowledge about a normal length of pregnancy came from their parents. Some women said they were given the information at health facilities, whilst some men learnt it in biology classes.

Generally participants perceived a difference between pre-term birth and miscarriage. Specific Chichewa terms exist for both of these. Most participants made the distinction that in their perception in a ‘miscarriage’ (in Chichewa, chitayo) the foetus is dead, whilst in premature birth (kuchila masika asanakwane) it can be alive. In addition, many said that in kuchila masika asanakwane the baby is fully formed, with recognisable features and genital organs. This baby looks like and counts as a person, and should be buried if s/he dies. In contrast, chitayo just looks like blood clots and water. There were some disagreements; some fathers, grandmothers and traditional healers said that a still-born baby that is fully formed is chitayo, whilst others said this was kuchila masika asanakwane, and others described this as kupita pachabe (literally ‘gone without outcome’), which appears to be primarily used for still born babies/foetuses who show no sign of life but are at the gestational age where clearly features can be distinguished. A minority of grandmothers and fathers made no distinction between pre-term delivery and miscarriage. Half of TBAs and traditional healers concurred with the majority view amongst the community, that there is a distinction between pre-term birth and miscarriage.

A majority of women in the community expressed the view that miscarriages occur earlier in a pregnancy, most defined a miscarriage as occurring up to six months into the pregnancy (particularly in the fourth or fifth month) whilst pre-term birth was thought to occur at seven to eight months. Not all agreed, however: a wide range of timeframes was given by a minority. Fathers seemed less sure about the difference, giving more varied definitions possibly reflecting men’s limited involvement in the process of pregnancy and childbirth. Mothers said that they had been taught the difference between pre-term birth and miscarriage at the clinic or hospital, told by parents or observed other people’s experiences.

Perceived causes of pre-term birth (Area 2, Figure 1)

There were few differences between the commonly perceived causes of pre-term birth and miscarriage and these are therefore discussed together. Where they apply only to one particular outcome this is indicated. In this and the following theme, there were no major differences between the perceptions of mothers, grandmothers and fathers. Where minor differences in views were expressed they are specified.

‘Modern’ illness categories

Illness was the most commonly expressed cause of both premature birth and miscarriage in the group discussions:

“If there is no problem in the body, the women can progress to full term. If she delivers prematurely it means she has some kind of infection” (FGD with mothers, #2).

This perception was confirmed by the participants in the critical incidence interviews - most women who had experienced premature birth thought it was at least partly due to illness.

Sexually Transmitted Infections (STIs) were the most commonly perceived illness causing pre-term birth and miscarriage. Common infections mentioned were syphilis, gonorrhoea and AIDS. Some mothers said that when premature birth is caused by STIs the baby is dead with sores all over it. A minority of fathers said that gonorrhoea or syphilis prior to pregnancy could cause premature birth by making the woman or the baby weak. Most women said that STIs are passed on to women by their husbands, but some attributed them to women’s promiscuity. Two women who had experienced premature birth attributed this to syphilis (CI 5 and CI 6). The majority of traditional healers and TBAs agreed with community participants on the importance of STIs as a cause of pre-term birth or pregnancy loss.

In addition to STIs, commonly mentioned diseases amongst community groups were malaria (mothers said especially when they experience frequent attacks) and anaemia (literally ‘when the woman does not have enough blood’). Most traditional healers, and some TBAs believed malaria to be one of the main causes. Most participants also saw general illness as a cause, and some gave examples of symptoms, including diarrhoea and vomiting, abdominal pains, headache, coughing, and backache. One of the women who had experienced premature birth attributed this to an illness mainly characterised by coughing (CI 1), another due to an illness involving coughing and vomiting (CI4) and another to diarrhoea and body pains, which she related to being beaten by her husband (CI 9) (this issue is discussed further below).

Traditional illnesses categories

Libale/ mauka/ likango

Some illnesses said to be responsible for both miscarriage and pre-term birth were perceived within traditional categories of health and illness. A majority described a related set of diseases termed libale, mauka, and likango. Most said that the three terms referred to the same illness; and some men explained that they are the same name in different dialects. Common symptoms ascribed to libale, mauka and likango were long’ or ‘flat’ growths, sores or blisters on the vulva, vagina, penis and/or anus (of both women and men). These sores or growths itch and release ‘water’ when scraped (all groups). The other major sign associated with this disease was frequent illness amongst children of same parents: for example, frequent diarrhoea, fevers and convulsions, serial still-births, or serial neo-natal mortality.

There are different perceptions of these traditional illnesses with regard to overlap, consequence and severity. Some participants, including mothers, TBAs and traditional healers, perceived several types of mauka: a severe type that causes neo-natal death, and a less severe type that does not. Libale and likango sometimes refer to the severe type.

’Libale and likango are a [severe] type of mauka... In some cases the woman or man would not develop growths but still have likango. The illness would manifest itself through dying of children. In other cases likango can show as growths on the genital area or anus of both men and women. If the growths burst a child dies in the family,” (Critical incidence interview with mother, # 1).

Most respondents agreed that libale, likango or mauka is ‘inborn’ or ‘inherited’ from one’s parents. Some specifically contrasted these traditional illnesses with STIs such as gonnorrhoea, HIV/AIDS and syphilis.

“STI are transmitted sexually whilst [likango/ libale /mauka] is inherited” (FGD with fathers, #4).

A minority distinguished traditional illnesses from STIs on the basis of their symptoms:

“[Gonorrhoea and libale] are different - when a woman has gonorrhoea the vagina is eaten up while libale are just small blister like growths” (FGD with mothers, #6).

However, a minority of mothers, fathers and traditional healers said that libale, likango or mauka can be sexually transmitted.

“Libale can be transmitted from man to woman or woman to man because I experienced it myself. All my childhood I never knew libale but when I got married, we had a baby and two months later the child started having fevers and my wife took the baby to a traditional healer where they found that my wife had libale which was scraped. When she came back I also noticed that I was developing an itchy and painful growth around my anus. I also went to the same traditional healer, who told me that I have libale…he said that I got the disease from my wife and if I had delayed I would have died” (FGD with fathers, #5).

Mwanamphepo

Mothers, grandmothers and traditional healers also commonly cited a condition called mwanamphepo as a cause of pre-term birth and miscarriage. Some disagreed, saying that the condition causes delayed delivery and infertility. Mothers and grandmothers said that the term describes both the illness and the traditional medicine that treats it. A wide range of symptoms were described for this illness across all groups. Common symptoms given included: lots of wind in the abdomen that makes a noise; feeling full even without eating; swollen/ distended body and/or abdomen; blocked passage during birth; and blisters or skin rash. Less commonly mentioned symptoms were: swollen eyes; swollen genitals; draining ‘water’; constipation; lack of appetite; vomiting and irregular menses.

Most participants agreed that mwanamphepo is an inborn illness, like libale/ likango/ mauka. A wide range of explanations for the illness were given, including different explanations by three traditional healers; these included ‘foam’ found in everyone’s body that increases in delivery, ‘wind’ in the abdomen, and sores in the abdomen, but all agreed that it could potentially harm the baby. Some grandmothers thought it came from witchcraft, whilst a minority of men said that it can be sexually transmitted, or caused by STIs such as gonorrhoea or syphilis.

Witchcraft

Most participants in all community groups saw witchcraft as responsible for pregnancy loss, but through witchcraft causing a pregnancy to ‘disappear’ rather than causing pre-term birth or miscarriage. The majority agreed that a pregnancy even in the sixth to ninth month, can disappear through witchcraft, with no illness, bleeding or pain.

“A woman may be pregnant when she goes to sleep…but the next morning she will find the pregnancy is gone and she is not bleeding at all, this means the witches have hooked it out” (FGD with grandmothers, #4).

Some mothers said miscarriage or pre-term birth as a result of witchcraft is no different from one due to natural causes, and only traditional healers can tell if someone has been bewitched. However, a minority of grandmothers and fathers said that they do not believe that witchcraft can actually cause either the disappearance of a pregnancy or pre-term delivery and compared this with other mistaken perceptions:

“In most cases it was mainly due to beliefs by elders that when someone has swollen feet it means that she has been bewitched, but when they go to the hospital, they are told that the swollen feet were due to lack of food. And with treatment they get better, so most of these are just beliefs” (FGD with grandmothers, #1).

One of the women who had experienced pre-term birth (CI 10) directly attributed her premature deliveries to witchcraft. Two others were told that their experiences were due to witchcraft, but did not believe this (CI 8 and CI3).

Violence

All groups commonly mentioned violence as a cause of both miscarriage and pre-term birth.

“Husbands are the cause of miscarriage and preterm delivery because they force us to do heavy duties while we are pregnant, and if we refuse they beat us,” (FGD with mothers, #2).

Mothers particularly mentioned being beaten frequently and both mothers and fathers commonly mentioned women being beaten on the abdomen. Several women who had experienced pre-term birth had also experienced physical violence during their pregnancies. One of these women attributed her pre-term delivery to diarrhoea and body pains, which she related to being beaten by her husband:

“I had a lot of family problems that time because my husband used to beat me from time to time. I feel that caused pre-term birth… that time he was smoking hemp and if I tried to reason with him he ended up beating me,” (Critical Incidence Interview with mother, # 9)

Impurity related to sexuality, death and blood

‘Impurity’ related to sexuality, death and blood was commonly seen as responsible for pre-term birth and miscarriage. A woman is designated as ‘hot’ or ‘impure’ if she is sexually active, has experienced a recent death in the household, or has vaginal bleeding (due to menstruation, or following miscarriage or delivery). If a pregnant woman comes into contact with ‘impurity’ this may cause pregnancy loss.

There are also a number of taboos associated with food preparation linked to the concept of impurity. All groups stated that a pregnant woman should not eat food that is already cooked or prepared; for example on sale at the market or provided at wedding or funeral feasts. This is because the woman preparing the food may be ‘hot’. Both of these can lead to generalised oedema, miscarriage, pre-term birth or death.

“If you eat food that is already prepared, it could be that the one who was cooking had sex the previous night, it is believed if a pregnant woman eats that she can easily miscarry” (FGD with mothers, #03).

Therefore only young girls and elderly women who are not sexually active can cook for a pregnant woman. However, some grandmothers said this is an old and mistaken belief.

It was commonly perceived that if a man has sex with another woman who has a disease, is menstruating or has a funeral in her home, and then has sex with his wife, this can lead to miscarriage. This is either because the other woman is ‘hot’, because this introduces ‘strange blood’ into the pregnant woman, which mixes with her own and the baby’s blood to cause ‘bad blood’, or because the other woman has a sexually transmitted disease like syphilis. Some grandmothers believe ‘bad blood’ can cause pre-term delivery and infertility. A minority said that ‘bad blood’ is a term for STIs.

A minority said that a pregnant woman should not have any contact with a dead body, go inside a house containing a dead body, or eat at a house where there is a funeral because this can lead to miscarriage, pre-term birth, or even death.

‘Heavy’ work

The majority of mothers perceived heavy work and ‘working all the time without a rest’ as a cause of premature birth and reported a lack of support from male partners to reduce their workload during pregnancy. A few grandmothers and fathers agreed that heavy work without sufficient rest is a cause. Fathers said this is particularly when the pregnant woman does not have enough to eat. Two women who had experienced pre-term birth said that heavy work might have contributed but were not sure about this (Critical Incidence Interviews # 2 and 10). .

Inappropriate use of medicine

The majority of participants, including traditional healers, agreed that a pregnant woman should not take any bitter medicine (modern or traditional). The most common examples of bitter western medicine included ‘capsules’ (generally antibiotics – specific mention was made of penicillin) and antimalarials (including suphadoxine-pyramethamine (SP)) Some said that these could be taken provided they had been prescribed. The majority agreed that taking any bitter medicines can lead to miscarriage and still-birth. It was commonly agreed that pregnant women should not take any modern medicine unless prescribed, because of not knowing which drugs a pregnant woman can take or the right dosage (some mothers said that aspirin was the exception to this rule).

“There are special drugs which are given to a pregnant woman at the hospital. She should not take drugs anyhow (i.e. without prescription)” (FGD with mothers #4).

There was general agreement amongst mothers, grandmothers and fathers that pregnant women should not usually take any traditional medicine; the main reason given for this was that traditional medicine has no dosage, so it may be too strong. A common exception to this rule was said to be taking a traditional medicine called mwanamphepo for prolonged labour. In contrast, the majority of traditional healers said that they will give pregnant women traditional medicine that is not bitter.

“Traditional medicine is not measured to get the correct dosage for an illness. Therefore pregnant women are discouraged to take these traditional medicines” (FGD with fathers #4).

No specific cause

Over half (6) of the women who had experienced a preterm birth said they did not know what had caused this. One said she was so young that she didn’t know what was going on when the delivery started. Another thought it was God’s wish, and that she just had to accept it. A minority of mothers and grandmothers put premature birth down to bad luck, or the ‘individual’s make up’.

Preventing pre-term birth: perceived strategies and barriers (Areas 3 and 4, Figure 1)

Despite identifying the many causes described above, mothers in both group discussions and in individual interviews commonly expressed the view that pre-term birth cannot be prevented.

“There is nothing we do. If you miscarry or deliver prematurely we just take it that it has happened. We never think of doing something; we think things have just happened”, FGD with mothers, #4).

When prompted about whether each specific cause of pre-term birth could be prevented, the majority of participants were able to identify some preventive strategies, although they also pointed out barriers to carrying these out.

Treatment of illness in pregnancy

Use of formal health facilities

Both husbands and grandmothers commonly said that pregnant women should go to formal facilities to attend Ante-Natal Clinic (ANC) ‘early’ (at 3 months), whenever they are ill, or think they have labour pains (this was stressed by grandmothers). Some specifically stated a preference for formal health facilities over traditional healers:

“The woman goes to the hospital for treatment first but if she does not get well it’s when she decides to go for traditional medicine. Only ignorant people rush to traditional healers with every illness. They just waste their time.” (FGD with grandmothers, #4).

However, many respondents said that in practice pregnant women do buy drugs from grocery stores or use what they have at home – aspirin, paracetamol or SP – before going to the hospital or clinic.

Despite viewing visiting (free) formal facilities as important, majority of mothers said that financial problems pose a barrier to timely preventive and treatment seeking behaviour because of lack of money to pay transport fees. Another barrier discussed by some, especially grandmothers, was the poor attitudes of staff at facilities:

“You think of going to the hospital but there they won’t help your child. Instead they will shout at you that your child is not doing the right thing…so when you think that your child will have problems at the hospital you just take her to a TBA who will receive you with respect. That’s why there are a lot of problems in the villages because they fear to go to the hospital because of what happens there” (FGD with grandmothers, #4).

Limitations on pregnant women’s ability to make decisions about where and when to visit healthcare providers and lack of practical support from family members were also discussed. Traditionally decisions about healthcare were made for pregnant women by parents (particularly mothers) A majority of fathers said that now they made the decision, often consulting parents in law or their wife’s uncle. There appeared to be some tension between husbands and parents about who should be the primary decision makers, but pregnant women themselves were rarely seen as being able to decide for themselves. Some fathers said that if a pregnant woman does not involve the husband in decision-making this will raise suspicions that the pregnancy is not his. Decision-making by pregnant women’s parents were seen by some husbands as a barrier to seeking formal care, as older people were said to prefer traditional healers and TBAs. However, FGDs with grandmothers themselves did not generally support this view, with the majority of participants stressing the benefits of modern healthcare. Several women interviewed said that lack of family support constrained their ability to deal with pre-term birth when it had happened.

Treatment and prevention of STIs

Although in principle most people agreed that treatment of STIs at formal facilities was important to prevent pre-term birth, communication between sexual partners over this issue was said to be problematic. The majority of grandmothers felt that a husband and wife should be able to discuss the issue and go for treatment together. However, mothers complained that husbands were often reluctant to go to a health facility for STI treatment. Some women said that husbands would get treatment if they were symptomatic but not tell their wives.

“Some men go for treatment secretly without telling you, so you do the same if you know what he is doing” (FGD with mothers, #7).

Mothers, fathers and grandmothers all agreed that when a woman is diagnosed with an STI this can result in quarrels, violence and even divorce as husbands often blame their wives for contracting the disease. Some men added that even when they are aware that they themselves probably transmitted the disease to their wife they accuse her of promiscuity.

“It is shameful to be told that your wife has STI even though you know you got it yourself. At first you will refuse and quarrel even telling her that she got it herself because you are ashamed to admit it, but eventually you will go together for treatment after quarrelling” (FGD with fathers, #5).

The majority of health care providers concurred saying that women are reluctant or afraid to tell husbands that they have been diagnosed with an STI, for fear of violence or abandonment. Some also noted that they often see women returning to the clinic due to re-infection because husbands were not treated.

In order to prevent STIs, all groups agreed that husbands should stop extramarital sex. Mothers said this is to avoid men infecting their wives with STIs, whilst grandmothers said it is to avoid giving her strange blood. However, men commonly said that they found it difficult to ‘control themselves’. A minority of mothers said that women should practice family planning, and discuss the use of condoms with their husbands to prevent STIs, but that they found it difficult to successfully negotiate for their use:

“If you want help you go to the hospital. They give you condoms but husbands accuse you that you are not faithful so they throw away the condoms” (FGD with mothers #1).

Rarely, women decide to separate from their husbands following an STI diagnosis, as illustrated by the case of a woman who had experienced multiple pre-term births, who divorced her husband when she discovered that he had syphilis. She made the discovery through a visit to the hospital following her third failed pregnancy. They both received treatment, but she said,

“I then told the man that I don’t want all my babies to go to the grave so I asked for a divorce …I will tell my fellow ladies that they should ask their husbands whether they have got any infection – they should go to the hospital early to have treatment to prevent premature birth” (Critical Incidence Interview #6).

Treatment of traditional illnesses

Some participants, especially fathers, saw the timely treatment of libale/ likango/ mauka as a strategy to prevent pre-term birth. The majority agreed that the growths or blisters associated with these conditions should be cut off or “scraped” by a traditional healer or TBA with a sharp razor, after which herbal medicine is applied to the vagina. Herbs are also used to bathe children suffering from fevers attributed to mauka. Tattoos may be cut to protect the woman from witchcraft. Some thought that libale could be treated at the hospital, whilst others disagreed. Others expressed shame to take this illness to the hospital because it affects their private parts.

“If elders know that it is mauka or likango then automatically these go to a traditional healer for treatment” (FGD with mothers, #7).

“She is taken to a female traditional doctor where she cuts it with a razor blade and then they give the woman and the baby some traditional medicine to drink. After that the fevers go away and baby gets well. If they don’t cut it the baby dies” (FGD with mothers, #4).

Three women who had experienced pre-term birth described receiving treatment for libale/ likango/ mauka. Two of these described having growths cut off by a traditional healer or older woman.

Two traditional healers said they did not scrape mauka off, but used herbal treatment vaginally. In addition, a minority of respondents, including mothers and TBAs, felt that the ‘milder’ type of mauka did not require cutting or scraping, but could be treated orally with traditional medicine. For example one woman said that she went to a traditional healer with growths and a sick child:

“The traditional healer told me that I was suffering from mild mauka which does not require scraping. We were just given the other treatment…a medicine which is given to the mother and child at once. The child is also bathed in herbal medicine once” (critical incidence interview with mother # 11).

Mothers, fathers, grandmothers and traditional healers agreed that for mwanamphepo, a medicine is made from mwanamphepo root, which can be taken as a fluid orally, used when bathing or mixed with porridge. However, many agreed that a pregnant woman should not take mwanamphepo medicine because it could lead to miscarriage

Table 3 summarises the other preventive strategies that were identified.

INSERT TABLE 3.

Discussion

1. An overview of key community interpretive frameworks emerging in the findings

We have presented four main themes emerging from our data: community conceptualisations of various birth outcomes (including chitayo, kuchila masika asanakwane, and kupita pachabe); perceived common causes; potential and commonly used strategies to prevent these outcomes; and perceived barriers to successfully following these strategies. As illustrated in Figure 1 all four themes are linked by the overarching interpretive frameworks of community members. Understanding these frameworks is central to capturing the understandings and conceptualisations of these complex interrelated phenomena. It is also important in identifying strategic entry points for dialogue with different community members.

We found that community members did have clear conceptualisations of pre-term birth as distinct from miscarriage or still-birth, although these differed slightly and were less precise than Western bio-medical definitions. There were a number of commonly perceived causes of pre-term birth and miscarriage, with little distinction made between the two in terms of causation. These included: modern illness categories; traditional illness categories; inappropriate use of medicine; witchcraft; impurities related to blood death and sexuality; poor nutrition; violence; and ‘heavy work’. The ‘modern’ illnesses perceived to cause pre-term birth were very similar to those identified by scientific research. However, several traditional illness conceptualisations radically diverge from Western bio-medicine in their aetiology and preferred treatments. It is easier to relate some of these ‘traditional illnesses’ to bio-medically recognised conditions than others. For example, the genital sores associated with mauka/liable/likango may be interpreted as genital warts, whilst the fevers and convulsions in children could be attributable to a number of conditions, including malaria. During ethnographic research on malaria on the southern lakeshore of Malawi Helitzer-Allen et al (1993) also found that one form of malungo (an illness complex roughly translated as malaria) was associated with the genital sores of mauka. In contrast, mwanamphepo appears to include a wide range of symptoms that it is difficult to translate into a bio-medically recognised pathology.

2. Building on community interpretative frameworks: Towards dialogue and action

Our data provides a starting point for the challenging project of enabling dialogue between community members and health professionals on these important health issues. The international health promotion literature provides numerous examples of ways in which health professionals and communities talk at cross purposes about the aetiology, prevention and treatment of diseases (Agyepong 1992; Nicheter 1994; Lambert 1998). Downie et al (1998) discuss the difference between ‘comprehension’ and ‘interpretation’ in the communication process, arguing that interpretation is influenced by a person’s ‘thinking framework’. Health promotion approaches from the perspective of Western biomedicine are unlikely to succeed unless they constructively engage with the multiple and complex ‘thinking frameworks’ existing in the communities they serve.

However, it is important to recognise that shared ‘thinking frameworks’ in any specific cultural and historical context do not exist in isolation from Western biomedicine. Hausmann Muela et al (2002) challenge the ‘traditional/biomedical dichotomy’ in health-related beliefs, arguing that most African settings have now been “medically pluralistic” for decades. They argue that, “local knowledge is the result of the amalgamation of the biomedical and traditional” and put forward the concept of “medical syncretism” to understand “the blending of biomedical with indigenous concepts” (ibid: 60). This concept is useful for understanding some of the ‘traditional’ disease concepts found in our study. Perceptions of STI symptoms may be seen as an example of ‘parallel coexistence’ wherein, “biomedical knowledge has penetrated into the traditional model but has neither displaced core notions nor merged with them”. Genital pathology may be interpreted as an STI within a biomedical framework, or as likango/ mauka/ libale, with markedly different implications for both treatment and prevention. Similarly, fevers and convulsions in children are open to ‘double causality’ as they may be perceived as a sign of malaria and/or mauka, and may thus have multiple treatment implications. This may also be considered as ‘complementary articulation’, whereby ethno-medical and biomedical explanations alternate and reinforce each other in explaining disease manifestations. In this case, the failure of a fever case to respond to malaria treatment is interpreted as evidence of mauka. Conceptualising community perceptions in this way helps us to understand the ways in which biomedical messages can be reinterpreted within people’s “thinking framework” (Downie et al 1998).

Figure 2 summarises how the interactions between community members and multiple healthcare providers influence perceptions of pre-term birth and preventive behaviour and also highlights the key strategic areas for action that are outlined below.

INSERT FIG 2.

Health sector responses to pre-term delivery need to be informed by community perceptions and grounded in the realities and challenges faced by women and men in poor, rural communities in Malawi. Drawing on the analysis and synthesis of experiences from the international literature a number of strategies are suggested namely: involving health care providers in the research process; developing strategies to enable interaction; building partnerships with non-formal health providers and identifying areas of common ground.

2. 1 Towards mutual understanding: engaging health care providers in the research process

Involving key health care providers such as nurse-midwives as members of the research team may be a first step towards ensuring that health promotion strategies build on fluid and complex community understandings of pre-term birth. The research midwives involved in the data collection and analysis for this study were new to qualitative research, but appreciated the opportunity to interact and communicate with community members in a more open way than is possible within a clinic encounter. Concerns have been raised about the extent to which the power relations between ‘lay’ people and health professionals may limit or distort the possibilities for collecting trustworthy information. We acknowledge that the positionalities of the research midwives as care providers to the study communities may have limited what respondents felt comfortable to talk about. Although sub-Saharan African perceptions of health and illness are often found to place emphasis on spiritual, social and psychological aspects (Feireman and Janzen, 1992) the views expressed by participants in our study concurred to a surprising extent with the bio-medical focus on illness as a cause of pre-term labour. It may be that participants focused on those issues they felt would interest the bio-medical researchers and/or that perceptions of the specific issue of pre-term labour have been influenced by interactions with bio-medical providers. In response to broader questions about protecting health in pregnancy used to open the discussions, some grandmothers discussed the importance of maintaining social harmony to avoid health problems caused by a mother’s disappointment or anger and witchcraft resulting from quarrels. That only grandmothers mentioned this may suggest that there has been a shift of emphasis between the generations. We were encouraged by participants’ willingness to discuss some beliefs and practices that are likely to contradict health education messages received from these providers, such as witchcraft and the treatment of traditional illnesses. Studies involving health workers as researchers have also found that this increased their understanding of community perspectives on different issues, ownership over interventions and their commitment to change (Aubel and Niang 1996; Khanna et al 2002).

2.2 Towards dialogue: Strategies to enable interaction

Modifying health education strategies and messages is a necessary but challenging part of responding to community perceptions. Simply refuting deep-seated cultural beliefs from the standpoint of Western bio-medicine is unlikely to be effective. Studies have shown that it is possible to enable community reflection on the potential positive and negative outcomes of traditional beliefs and practices, which can lead to community decisions on appropriate modifications to their practices (Shaw 2002; Howard-Grabman et al 2002; Melching 2001). We used drama to feedback the findings of the research to community members. Drama may be a useful starting point in engaging communities in this process of reflection, because of its ability to portray the complexity of beliefs and practices through the use of a range of characters and situations, rather than prescribing ‘correct’ or ‘incorrect’ behaviour. Positive outcomes of involving those who influence pregnant women’s interpretations of ill-health and health seeking behaviour, such as grandmothers, have also been reported (Aubel et al, 2001). Although we were slightly surprised by how few differences in perceptions we found between the generations, our study confirmed the influence of older people, particularly grandmothers, and thus the importance of involving them in strategies for change.

2.3 Building partnerships with non-formal health providers

Non-formal health providers, such as traditional healers, traditional birth attendants and grocery store owners are important in the Malawian context, especially amongst poor communities where there are a number of barriers to accessing formal health services (Nhlema et al 2006). Their influence on health-promoting and care-seeking behaviour during pregnancy, (including responses to infections) illustrates the importance of building new partnerships between these providers and formal health professionals/providers. The common concern about pre-term birth could provide a platform for this in the Namitambo area. In-depth interviews with traditional healers suggested a general reluctance to treat pregnant women themselves and their willingness to collaborate with the formal health sector. This is important, if traditional treatment is sought in preference to bio-medical treatment for conditions easily treatable by bio-medicine. Women may be missing out on care that could prevent pregnancy loss or pre-term birth.

Working with traditional providers can raise its own dilemmas for biomedical health professionals who are understandably reluctant to legitimise certain harmful practices by ‘medicalising’ them. Some of the treatments described for traditional illnesses may be harmful. For example, the ‘scraping’ of genital sores associated with mauka/liable/likango potentially carries a risk of spread of infection including HIV.. Providing information and equipment on using a sterile technique for the excision of warts might prevent this, but could also appear to legitimise this practice, which may have other harmful consequences for health. Similar dilemmas have been faced in efforts to eliminate the practice of Female Genital Mutilation (FGM) (Shell-Duncan 2001; Shaaban and Harbison 2005). Although there is no easy resolution to this dilemma, it is possible to develop an approach that combines short-term harm reduction strategies with longer term efforts to stimulate community-level reflection and change.

2.4 Identifying areas of common ground and shared belief

Our data also illustrate areas of shared beliefs between health professionals/ biomedical science and the Namitambo community. One such area is their agreement on the importance of infections as a cause of poor pregnancy outcome, which could act as a basis for moving towards common ownership of biomedical interventions that address infection.

Preventive and curative care at formal facilities is not currently addressing many of women’s perceived needs for preventing pregnancy loss and neo-natal mortality as a result of pre-term birth. In addition there is an urgent need to develop closer linkage between the various (currently separate) health promotion and disease control programmes for eg malaria, HIV, STIs and Reproductive Health Care, within the potentially enabling umbrella of the emerging Health Sector Wide Approach in Malawi, to ensure that at the very least they provide complementary and consistent messages.

Common concern about pre-term birth and poor pregnancy outcome could be a key starting point for medical and social interventions to improve women’s health and well being. Our data shows that women are concerned with a number of threats to their well-being during pregnancy beyond the single outcome of pregnancy loss, including violence, poor nutrition, and overwork, which are often related to lack of material and psycho-social support. Poor pregnancy outcome itself also has broad-reaching emotional, psychological, cultural and socio-economic impacts. In the experience of health workers involved in the study, women tend to present at health facilities for investigation after losing a pregnancy (or newborn child), because of the emotional and social pressure placed on them by the community. Repeated pregnancy loss (and new born death) can threaten a woman’s life and health by exposing her to the risk presented by repeated pregnancies in order to attain the desired family size. Our study shows that it can also have social effects such as the breakdown in the marital relationship, with potential negative impacts on the woman’s social and economic status. Women do not take decisions about their health and well-being in isolation and the perceived causes of poor pregnancy outcome clearly have social dimensions. Gender inequities underlie many of the causes of pregnancy loss and pre-term delivery, and barriers to preventing them; including gender-based violence, women’s relatively low access to and control over resources, and limited decision-making power with regard to their own sexual behaviour, health and fertility. Efforts to address the problem cannot therefore focus on medical interventions or the pregnant woman alone; they must work to improve women’s socio-economic status and to strengthen the support they receive from other family and community members. This also involves building strategic partnerships beyond the health sector and linking with the efforts of the Ministry of Gender, Youth and Community Services and civil society to address gender based violence and support women’s empowerment, including ability to negotiate safe consensual sex and access to health services. Further explorations of community perspectives on the socio-economic and psychological impact of high levels of pregnancy loss would also be helpful to identify common concerns as a basis for interventions beyond healthcare.

3. Situating responses within the challenges of resource poor settings

Finally, criticism has been levelled at and ‘rapid assessments’ of socio-cultural factors related to health and applied medical anthropology more generally because they have tended to focus largely on cognitive and ‘cultural’ factors amongst ‘lay’ people to the detriment of exploring their location in the socio-economic structures and power relations which have the greatest influence on health and illness (Farmer, 1999). Although this study has focused on the socio-cultural aspects of pre-term birth, it is important to recognise that structural forces such as income poverty, lack of food security as well as limited availability of quality healthcare are arguably the primary determinants of the poor pregnancy outcomes found amongst Malawian women.

Conclusion

Our study has shown that there are currently ‘gaps’ between the understanding and priorities of health care providers and community members with regard to pregnancy loss and pre-term birth, as well as some shared beliefs and concerns. Further dialogue and action is needed building on shared concerns to develop strategies for improving pregnancy outcome. Such strategies need to go beyond bio-medical risk factors and address women’s broader health and well-being concerns and the structural barriers they face to protecting their health.

Acknowledgements:

This study was funded by the DFID Malaria Knowledge Programme at the Liverpool School of Tropical Medicine and by the Wellcome Trust. The views and opinions expressed are those of the authors alone. Special thanks to the midwives and staff of the Wellcome Trust Centre in Blantyre, who conducted the data collection and transcription, and to the women and men who generously shared their perceptions and experiences.

Table 1: Respondents and Methods

|Method of data collection |Number of groups / interviews |

|Focus group discussions | |

|Mothers |7 groups* (68 women) |

|Fathers |5 groups (53 men) |

|Grandmothers |5 groups (56 women) |

|Total Focus Group Discussions |17 groups (177 participants) |

|‘Critical incidence’ interviews | |

|Women who have experienced pre-term birth |11 women |

|Total Critical incidence interview |11 interviewees |

|Key informant interviews | |

|Clinic health workers (all levels**) |5 |

|Traditional Birth Attendants (TBAs) |5 |

|Traditional healers |3 |

|Total key informant interviews |13 interviewees |

* 6-14 participants in each group

** Including the medical assistant, nurse-midwives, community nurses and health care assistants.

Table 2: Characteristics of participants

|Respondent group |Age range |Marital status |Religion |Educational status |

|Mothers |18-46 (majority |Majority married |Majority Christians, but|Majority had some primary |

| |between 20 and 40) | |some Muslims |education. |

|Grandmothers |36 – 79 (majority |Half married; remainder |Majority Christians, but|Half had no education; majority |

| |between 40 and 60) |divorcees or widows |some Muslims |of remainder had some primary |

| | | | |education. |

|Fathers |22 - 83 |All married |Two thirds Christian and|Majority had complete primary |

| | | |the remainder Muslims |education and a significant |

| | | | |minority had some secondary |

| | | | |education. |

|Women who had experienced|22 – 47 (just under |All but one married. 1 |No information. |Majority (6 out of 11) had some |

|pre-term birth |half were in their |widow. 4 had married more| |primary education; 4 had |

| |twenties) |than once. | |complete primary education; 1 |

| | | | |had none. |

|Traditional healers |38 - 51 |All married |No information |No information |

|TBAs |45- 66 |No information |No information |No information |

Table 3: Other preventive strategies

|Cause of pre-term |Strategy (respondent group) |Barriers to implementing |

|birth | |strategy |

|Impurities (blood, |Avoid prepared food (majority) | |

|sexuality and death) |Herbal remedies for ‘bad blood’ (traditional healer) | |

|Violence |Men be more patient with their wives, rather than beating them | |

|Poor nutrition |Men should provide a balanced diet for their pregnant wives (majority of|Poverty and unemployment |

| |grandmothers and fathers) | |

| |The clinic should provide milk, vitamin tablets and ufa (maize flour) to| |

| |the women as well as drugs | |

|Witchcraft |Pregnant women and their families should avoid quarrelling with people, | |

| |which gives witches an opportunity | |

| |a pregnant woman should not be taken to traditional court for a case if | |

| |she has quarrelled with someone till she delivers | |

| |Traditional healers cut tattoos and give herbal medicine to prevent | |

| |witchcraft | |

|Hard manual work |Avoid heavy labour |Husbands may beat their wives |

| | |if they try to avoid hard work |

Figure 1: Summary of the study findings

[pic]

Fig 2: Interactions influencing perceptions of pre-term birth and preventive behaviour (version 2)

Key:

Current interactions

Suggested influences of research, dialogue and action

-----------------------

1. community conceptualisations of pre-term labour and miscarriages

• Chitayo

• Kuchila masika asanakwane

• Kupita pachabe

2. Perceived causes of pre-term labour and miscarriages

• Bio-medical , ‘modern’ illnesses

• Traditional illnesses

• Witchcraft

• Violence

• Impurity related to sexuality, death and blood

• ‘Heavy’ work

• Inadequate food or nutrition

• Inappropriate use of medicine

• No specific cause

3. Main perceived strategies to prevent pre-term labour and miscarriages

• Use of formal health facilities for preventive and curative care

• Partner notification and treatment for STIs

• Condom use

• Avoiding promiscuity

• Traditional treatment of traditional illnesses

• Prevention of witchcraft by traditional healers

• Avoiding violence

• Avoiding prepared food

• Reducing workloads

• Eating a balanced diet

4. Main barriers to preventive strategies

• Lack of money for food, treatment or transport to facilities

• Distance to facilities

• Secrecy between couples

• Violence towards women

• Male refusal to use condoms

• Women’s low decision-making power

• Lack of family support

Community interpretive frameworks

2. Towards dialogue: strategies to enable interaction

Perceptions of causes of pre-term labour

Preventive measures against pre-term labour

Experiences of formal health service use

Interpretive frameworks

Understanding perceptions of causes

Poverty and gender inequality

Accessibility of formal health services

Understanding perceived quality of health services

3. Building partnerships with non-formal providers

Messages from traditional healers and TBAs

Experiences of traditional healer use

Pregnancy outcome

Multi-faceted impact

Reproductive decisions

1. Towards mutual understanding: engaging midwives/health workers in the research process

4. Identifying areas of common ground and shared belief

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